Politics–evidence conflict in national health policy making in Africa: a scoping review

Background Generally, public health policy-making is hardly a linear process and is characterized by interactions among politicians, institutions, researchers, technocrats and practitioners from diverse fields, as well as brokers, interest groups, financiers and a gamut of other actors. Meanwhile, most public health policies and systems in Africa appear to be built loosely on technical and scientific evidence, but with high political systems and ideologies. While studies on national health policies in Africa are growing, there seems to be inadequate evidence mapping on common themes and concepts across existing literature. Purpose The study seeks to explore the extent and type of evidence that exist on the conflict between politics and scientific evidence in the national health policy-making processes in Africa. Methods A thorough literature search was done in PubMed, Cochrane Library, ScienceDirect, Dimensions, Taylor and Francis, Chicago Journals, Emerald Insight, JSTOR and Google Scholar. In total, 43 peer-reviewed articles were eligible and used for this review. Result We found that the conflicts to evidence usage in policy-making include competing interests and lack of commitment; global policy goals, interest/influence, power imbalance and funding, morals; and evidence-based approaches, self-sufficiency, collaboration among actors, policy priorities and existing structures. Barriers to the health policy process include fragmentation among actors, poor advocacy, lack of clarity on the agenda, inadequate evidence, inadequate consultation and corruption. The impact of the politics–evidence conflict includes policy agenda abrogation, suboptimal policy development success and policy implementation inadequacies. Conclusions We report that political interests in most cases influence policy-makers and other stakeholders to prioritize financial gains over the use of research evidence to policy goals and targets. This situation has the tendency for inadequate health policies with poor implementation gaps. Addressing these issues requires incorporating relevant evidence into health policies, making strong leadership, effective governance and a commitment to public health.


Introduction
The state of human health varies globally, such that long-term human security is endangered at multiple levels [1,2].Current and future efforts aimed at containing and improving population health and well-being are expressed in many national health policies [3].A national health policy is a planned course of action carried out by a country or state to attain defined healthcare goals [4][5][6].Perhaps, public policy-making and its processes are at the instance of the political leaders [1].Generally, public policy-making is hardly a linear process, characterized by interactions between and among politicians, institutions, researchers, technocrats and practitioners from varied fields, as well as brokers, interest groups and a gamut of other actors [5].Right from its inception through to review, the policy-making process can be burdened with serious rifts, especially among the principal actors such as politicians, researchers and technocrats [7] which could place limitations on the use of evidence to inform the policy.
There are several frameworks for policy analysis, but the health policy triangle (HPT) by Walt and Gilson [8,9] gained popularity.The HPT consists of four main constructs, including the policy context, policy content, policy process and the policy actors.The policy context refers to the socioeconomic, political, cultural and other environmental variables that necessitate the policy [8,9].The policy content refers to the core policy objectives, regulations and legislations that underpinned the policy.The policy process refers to how the policy evolves, from conception, formulation, negotiation, communication and implementation to evaluation.Moreover, policy actors refer to significant individuals, groups and institutions that influence the policy process [8,9].Thus, critically following the tenets of this framework may lead to formulation and implementation of health promoting policies that help lesson the burden of ill health on Africa.Meanwhile, a robust and evidence-based health policy is most likely to guarantee equitable and optimum human health [10].
Furthermore, it is believed that health policies in Africa are driven largely by political rather than technical interests backed by robust evidence [3].However, factors such as funding, scientific evidence, interest and activities of lobbyists, and political interest/commitment influence national health policies [3,11].The policy-making process, either driven by need, evidence based or political interest, determines the core policy objectives and how they are attained.Thus, poorly crafted and implemented health policies in Africa, for instance, challenge access to quality health because of poor funding, corruption, equity and quality gaps, making such policies ill-prepared for national emergencies [1,7,10].Meanwhile, universal health coverage by WHO, re-echoed in the Sustainable Development Goals (SDGs), remains a dream for the majority of countries in Africa [1,12].Therefore, this conflict between the use of political goals and objectives over research evidence in public health policy-making needs exploration.
Several studies have revealed that public health policies and systems appear to be built loosely on technical and scientific evidence, but with high political systems and ideologies [13][14][15][16].For instance, in most African countries such as Ghana, Kenya, Nigeria, South Africa, Tunisia, and Zimbabwe, the management of the novel SARS-CoV-2 pandemic and the public health response have been heavily politicized [16][17][18].Regardless of the seeming increase in research evidence on the central role of political leadership in defining national public health policies in Africa, there seems to be inadequate empirical accounts of the common themes or concepts in the existing literature regarding the politics-evidence conflict in the public health policy-making process [18,19].For instance, though evidence exists of the advances in knowledge about evidence-led health policies [19], research on the politics-evidence relationship remains largely unclear.Furthermore, while studies on health systems strengthening gave prominence to the role of technical knowledge in public health policy effectiveness, evidence on how politics shapes health systems is unclear [20,21].However, such health development in Africa is largely driven by politics [16][17][18].Clearly, there is the need to establish the common themes and concepts that cut across the existing literature on the subject under discussion.Therefore, to fill this research gap, this review scoping explores the extent of evidence in relation to politics and scientific evidence utilization in the national health policy-making process in Africa.

Materials and methods
We utilized only peer-reviewed articles to examine the relationship between politics and scientific evidence in the national health policy-making processes in Africa.We utilized the approach of Tricco et al. [22] in probing, synthesizing and analysing appropriate peer-reviewed articles.The approach includes (i) outlining and developing the purpose of the review, (ii) outlining and critically examining the review questions, (iii) identifying and scrutinizing article search terms, (iv) identifying and exploring related databases and downloading useful articles, (v) screening the data, (vi) summarizing the data and reconciling the results, and (vii) consulting [22].Therefore, two research questions informed the review: (1) what is the nature of politics-evidence conflict in national health policy-making in Africa?and (2) what are the challenges with politics-evidence conflict in national health policy-making in Africa?
This paper was also guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension (PRISMA) [22,23].We sourced peer-reviewed records from the following databases/search engines/ publishers: PubMed, Cochrane Library, ScienceDirect, Dimensions, Taylor and Francis, Chicago Journals, Emerald Insight, JSTOR and Google Scholar (see Fig. 1 and Table 1).To guarantee rigidity and comprehension in the search procedure, medical subject heading (MeSH) terminologies were used.The search was conducted at two levels: level one applied the terms "Health policy*" OR "Health politics*" OR "Policymaking*" OR "Policymaking*", which produced 186 articles.At the second   Following the initial search, duplicate articles were imported into and merged in the Mendeley.To attain rigour in the screening, four authors (2, 3, 4 and 5) did the initial screening of titles and abstracts.Subsequently, all articles that passed the inclusion criteria (defined below) were thoroughly reviewed.Doubts over the qualification of an article were resolved by two authors (1 and 6) through detailed discussion until a consensus was reached.With the PRISMA protocol, citation chaining was conducted on all papers that qualified, to identify additional useful articles for further assessment.The first author led, supervised and substantially helped to resolve all discrepancies during data extraction and quality assessment processes.

Inclusion criteria
Studies about Africa that explored evidence-politics conflict in national health policy-making processes and written in the English language only were included for studies done between 1 January 2010 and 31 December 2023.Additionally, articles must have given details on the author(s), purpose/aim, methods/setting, nature of politics-evidence conflict, type of health policy, impact of politics-evidence conflict and conclusion/ recommendations.

Exclusion criteria
We excluded articles that were not peer reviewed and those with substantial limitations or poor quality.Also, commentaries, grey literature, opinion pieces and media reports were excluded from this review.Articles on politics-evidence conflict that were not conducted in Africa were excluded.

Quality rating and assessment
Using the procedure of Tricco et al. [22], articles that met the inclusion criteria went through quality rating.Articles that provided background, aims/objectives, context, appropriateness of design, sampling, data collection and analysis, reflectivity, the value of research and ethics were accepted.Thus, the articles were judged and total scores assigned based on the majority of the sections.Articles that scored "A" had few or no limitations, "B" had some limitations, "C" had significant limitations but possessed some relevance and "D" contained substantial flaws that could undermine the findings of the study.Therefore, articles that scored "D" were excluded from the review.

Data extraction and thematic analysis
Five authors (2, 3, 4, 5 and 6) independently extracted the data.Three authors (2, 3 and 4) extracted data on the author(s), purpose/aim, methods/setting, nature of politics-evidence conflict and type of health policy.Meanwhile, two authors (5 and 6) extracted data on the impact of politics-evidence conflict and conclusions/ recommendations (see Table 2).Data extraction was done under the supervision of authors 1 and 6.Using the method of Braun and Clarke [23], a thematic analysis was conducted by three authors (1, 4 and 6).Therefore, data were coded and the themes emerged inductively and yet guided by the stated research questions.The data analysis commenced with multiple readings of the text to familiarize with the data, we then created initial codes, critically assessed the themes, revised the themes, defined and labelled the themes, and produced the report.Additionally, the emerged themes went through exhaustive discussion by all authors to reach a consensus.The themes further went through repeated reviews based on new data until the final themes emerged.

Nature of politics-evidence conflict in national health policy-making in Africa
Our review revealed some form of competing interest in national policy dialogue, from formulation to implementation phases.The most commonly reported conflicting issues include confusion about policy priorities with political ideologies, donor interests and influences [24][25][26][27][28][29][30]51].We also found that moral, legal restrictions and government priorities are key competing interests in most African countries concerning national health policy-making.Wanjohi et al. [28] noted that governments have competing roles, for example, the sugar-sweetened taxation policy in Kenya.
It emerged also that donor financing facilitated the process of national public health policy, but strategically skewed the power balance and goals of some health policies [24,40,41].In some cases, donor powers were used in the positive direction, but negatively in others [29,[41][42][43][44].Moreover, power imbalances associated with funding sometimes disrupt the flow of funds from donors, something which negatively affects the content and original purpose of national public health policies in Africa [41,42,45].

Drivers of public health policy-making in Africa
We found that political commitment and strong collaboration among actors, stakeholders and development partners drive public health policy formulation [29, 33, 34, 36-38, 44, 46, 62].Also, strong existing policies and legal frameworks, employing evidence-based approaches in the policy formulation process, self-sufficiency, prioritization of basic needs and acknowledging weaknesses in the national system and taking measures to resolve such improve policy dialogue [29,34,44].
It also emerged that strong government leadership and empirical-based approaches, effective engagement of experienced stakeholders, policy alignment with political priorities and evidence-based interventions are effective in policy formulation [46].Furthermore, social, political, economic and institutional factors influence the effectiveness of national policy processes [35,39,47,49,50].Additionally, the integration of national policies into international ones and formulation of new policies were driven by stakeholder interests, advocacy and collaborative efforts from civil society and the global advocacy movements [34,47,66].

Barriers to national public health policy-making in Africa
We found that fragmented stakeholder interest, institutional responsibility and accountability, inadequate understanding and interpretation of context by stakeholders divided perspectives of actors on the policy context, and lack of understanding among actors about how policy should be financed limits national public health policy formulation [27,30,41,[51][52][53].Moreover, incomplete and inaccurate data, poor management of resources, improper coordination and communication between actors, inadequate consultation with relevant stakeholders and inconsistency among actors during policy dialogue and formulation processes are also critical limitations to policy formulation [26,40,41,[52][53][54][55].
Furthermore, it emerged that a lack of strategic leadership and a clear action plan regarding policy processes, poor characteristics of political players and difficulty in understanding and interpreting context by stakeholders frustrate policy processes [25,28,32,35,37,53,54,59]. Additionally, lack of decentralization of policy formulation and implementation, poor resource mobilization and lack of political engagement with policy beneficiaries, implementers and other relevant stakeholders suffocate some policies in the continent [38,51,53,56].Besides, most national public health policy processes were motivated by policy-makers' financial incentives as well as government and foreign policy conditionalities in Africa [27,36,40,46,57].

Impacts of politics-evidence conflict in public health policy-making
There are delays in policy dialogue and implementation due to disparities between policy expectations and actual practice, weak policy processes that do not take into account the relevant actors and lapses in policy context [24,42,48,51,55].We also noticed delays in the policy formulation process due to high political and external conflict [25,28,30,37,53].Moreover, due to poor engagement with policy players, fragmented governance and weak monitoring systems, some health policies do not meet their intended purposes [33, 37, 38, 41, 43-45, 54, 57-59].
Fortunately, evidence suggests a consensus among actors in the policy process which promotes collective ownership, high political commitment, pressure from civil society and other relevant stakeholders as well as policy alignment with political priorities that led to some successes in public health policy formulation [29, 31-34, 46, 51, 60].

Discussion
Strong empirical evidence is the backbone for impactful national health policy.Pursuant to this, we explored the extent of evidence of conflict of politics and scientific evidence in the national health policy-making process in Africa.The study revealed four significant themes under which the discussion is organized.These include political influence in public health policy, drivers of public health policy, barriers to effective public health policy and impact of politics-evidence conflict on public health policy-making process in Africa.

Political influences in public health policy
We report that public health policies in Africa are heavily influenced by politics rather than scientific evidence.Most governments succumbed to donor interest which largely define the policy process [28,30,37].This is consistent with several previous studies [1,13,19,20] who reported similar findings.Meanwhile, the interests of these donors are often at variance with the health needs of the citizenry in Africa.Moreover, affirming previous studies [13,19], our current study exposed the influence willed by donors which reiterates the power imbalance and lack of independence that sometimes characterizes policy-making in Africa to the detriment of its local needs.
In contrast to the findings of the current study, an earlier study [20] recognized the role of political ideology in the national health policy process.Meanwhile, the reviewed articles [24,45,47,48,57] showed that political influence undermines policy formulation that cater for sustainable health development in the continent.For instance, Oleribe and colleagues [67] attributed the failure of abortion policies in Burkina Faso and other sub-Saharan African countries to political influence and poor stakeholder consultation.This could be largely due to limited financial capacities and impositions by global organizations and allegiances.

Drivers of public health policy
We found that, generally, the main drivers of public health policies in Africa include health organizations, donor agencies, development partners, political manifestos and nongovernmental agencies [34,35,38].For instance, a review of the National Health Insurance Policy of Ghana revealed that its success stemmed from its alignment with the political manifestos of successive governments [36].This agrees with previous studies [2,3] which revealed how donor agencies, development partners and political manifestos drove public policies.Furthermore, global agencies such as WHO, United Nations Development Programme (UNDP) and others collaborate very much to drive the health policy directions, especially the less developed nations, in meeting global health standards such as the SDGs for health.Thus, strong advocacy and partnership influence policy direction in all affiliate countries.

Barriers to effective public health policy
The main barriers affecting an effective public health policy-making process in Africa include poor consultation, orientation and decentralization [26,29,36].Typically, political policies are expected to promote stakeholder consultation, orientation and proper decentralization of health interventions.However, we found that political policies and activities are rather undermining stakeholder consultation, orientation and proper decentralization of health interventions [26,29,36].This strongly upholds findings from previous studies [3,5,15,16] that political interests undermined successful implementation of national policies.This is mostly because governments in Africa lacked adequate resources and empirical evidence to effectively drive health policy process to a successful implementation [30,41,45,47].Unfortunately, disparities in expectations and systems account for lapses in the policy context and the entire formulation process [28,32,44,53,61,62].Some previous studies [5,16] have reported how implementation of public policies fell short of public expectations.Moreover, leadership corruption, inadequate consultation, poor advocacy and inadequate use of core evidence in policy-making and implementation compromise the future of public health in Africa.

Impacts of politics-evidence conflict on public health policy
We found that competing interests, political dishonesty and lack of political commitment affect the expected health needs of many African populations [24,26,51].Poor coordination of key policy actors such as donors and other stakeholders, coupled with poor integration of global goals into local health policy frameworks undermined intersector participation which results in poor health policy formulation and implementation [24,26,51].According to previous studies [15,68], health policies of most developing countries are driven by political propaganda that often does not deal with the critical health needs of the citizenry.Meanwhile, the evidence is that in a few countries where health policies are led by empirical evidence and supported by political commitment, health indicators improved [63,64].For instance, we found that in Kenya, Ethiopia and South Africa, effective participation of healthcare professionals and other key stakeholders in developing policies on abortion lead to significant reductions in mortality due to illegal abortions [63,64].Then, effective stakeholder participation becomes key to the success of public policy implementation [15].Therefore, effective decentralization and stakeholder participation, specifically the targeted beneficiaries and healthcare professionals, are necessary to engender effective policy implementation.

Alignment of findings with policy frameworks
The current review aligns well with Walt and Gilson's policy framework.First, we found that donor interests, mostly championed by political interests (policy context), largely define most national health policies in Africa [28,30,37].Second, rather than evidence-based policy objectives and legislations, the contents of most national health policies in Africa do not align well with the needs of the locals (policy content).This creates misalignment in policy in objectives and content to the detriment of the health of the African citizen.Thus, the content of most national health policies failed to address the critical health needs of the ordinary African citizen.Third, such policies are driven by donor interests that are supported by political interest (policy process) into key policy activities from policy conception, formulation, negotiation and communication to evaluation [24,26,51].Fourth, on the policy actors, key stakeholders such as health professionals, academia and community leaders do not actively participate in the policy process in Africa.This ultimately undermines policy ownership and implementation success [5,16].

Strengths and limitations
This study is a significant addition to existing empirical accounts of the politics-scientific evidence conflict in the national health policy-making process in Africa.To uphold compression and rigour in the search procedure, we applied the MeSH terms in search of only peer-reviewed articles on the variables.Additionally, we set inclusion and exclusion criteria, and the reviewed articles went through a rigour of quality rating, using standardized guidelines.Moreover, data extraction was independently conducted and verified by all authors.These notwithstanding, there are limitations worth acknowledging.First, including only peer-reviewed articles that are written in the English language and covering only Africa may have limited the literature samples used in this study.Thus, some excluded articles, written in other languages, may contain important details.Moreover, we acknowledge that the inherent weaknesses and biases in the reviewed articles are carried into our research.

Recommendations for policy direction and research
Based on the findings from this review, we reiterate evidence-based agenda setting before any policy process.More importantly, policy-makers should research and establish strong evidence to demonstrate the viability of the proposed policy.Additionally, government and political leadership may want to limit corruption and be committed to ensuring that the policy agenda meets the immediate local needs and that global policy initiatives do not undermine pressing domestic health needs.Furthermore, it is recommended that all stakeholders, including implementers and beneficiaries, are engaged and fully participate in the entire policy process.Finally, we recommend that all stakeholders have a common understanding of the policy agenda and what is expected to achieve, and remain resolute to the collective purpose through the policy processes.

Conclusions
The extent of political-evidence conflict in national health policy processes is marked by obstructions.There are issues related to corruption, where political interests prioritize their financial gain over the needs of the healthcare system and the public.The potential impact on health in Africa is an increase in disease burden, lack of productivity and lack of progressive health development.There is largely inadequate funding for healthcare, a situation that is resulting in poor public health policy implementation leading to inadequate availability of essential medicines and supplies, and causing other negative impacts on public health.
Addressing these conflicts between political interests and evidence into health policy formulation and implementation require strong leadership, effective governance and commitment to the public health agenda.It also requires collaboration between and among different stakeholders, including government officials, healthcare providers, researchers and civil society organizations.By working together, it is possible to develop policies and strategies that are evidence based, equitable and sustainable, that promote the health and well-being of all persons in Africa.

Appendix
See Table 2.The policy was internally driven with minimal external influence.There was a strong collaboration between government and civil society, and this is the major driver of the success achieved

Table 1 Search strategy Search strategy item Search strategy
(1)Media reports; (2) grey literature; (3) PRAs published before 1 January 2010 and after 31 December 2023; (4) PRAs outside of Africa; (5) articles devoid of details on author(s), purpose/aim, methods/setting, nature of politics-evidence conflict, type of health policy, consequences of politics-evidence conflict and conclusion/recommendation; (6) reviewed articles and (7) articles with a low-quality rating